성공적 경피적 관상동맥 확장성형술후 나타나는 재협착과 영향 인자

석준호(Jun Ho Seok),김성목(Sung Mok Kim),배성화(Sung Hwa Bae),김봉준(Bong Jun Kim),윤지성(Ji Sung Yoon),이학준(Hak Jun Lee),신동구(Dong Gu Shin),김영조(Yeong Jo Kim),심봉섭(Bong Sup Shim) 대한내과학회 1998 대한내과학회지 Vol.54 No.5

Objective: Restenosis after successful PTCA remains the main limitation of this technique. Restenosis is a response to injury of the vessel wall, platelet aggregation, thrombus formation, liberation of growth factors, cellular hyperplasia involving predominantly smooth muscle proliferation and migration, and intercellular matrix formation. The identification of risk factors for restenosis could help to prevent and reduce the impact of this phenomenon. We undertook this study to evaluate retrospectively the association between risk factors and restenosis after PTCA Methods: We studied 123 patients and 174 lesions that underwent successful P1YA and the follow-up period (from PTCA to follow-up angiography) was 8.2±5.8 months in all patients. They were divided into two groups according to the restenosis. Clinical feature, lesional feature, PTCA procedural feature, and other risk factors were compared. Restenosis was defined as the cutoff paint of >50% in diameter stenosis at angiographic follow-up. Results: 1) Restenosis was found in 68 lesions after successful PTCA (39.1%), 2) Clinical features of restenosis group are similar to no restenosis group 3) Thrombus (p=0,002), total occlusion (p=0.001), severity of stenosis in the initial lesion (p=0.013) and residual stenosis (p=0.001) were found to be independently associated with restenosis, whereas other lesional characteristics were not. 4) Balloon inflation duration (p=0.017) and dissection (p=0.002) were found to be independently associated with restenosis, whereas other procedural characteristics were not. Conclusion: Thrombus, total occlusioo, dissection, severity of stenosis in the initial lesion, balloon inflation time, residual stenosis were found to be associated with restenosis after PTCA in our study.

관상동맥질환 환자에서 스텐트 시술 후 재협착에 관한 연구

강진환,권영주,박상호,한대희,이상철,김명구,변정득,최병조,심규혁,온영근,현민수,김성구 순천향의학연구소 2001 Journal of Soonchunhyang Medical Science Vol.7 No.2

Background and aims : In the coronary artery disease, a rate of restenosis was much decreased by placement of coronary stent than when percutaneous transluminal coronary angioplasty has been applied, but there are still important clinical problems of restenosis. There has been many progressive studies about various factors contributed to this restenosis. So, we studied a relation between restenosis after placement of coronary stent in the coronary artery disease and many clinical factors, characteristics of stenotic lesion and procedural factors, and also assessed the restenosis rate of various coronary stents. Methods : Total 58 lesions(46 cases of patients ; man 30, woman 16) were evaluated, which has been performed a follow-up coronary angiography after 6 months (mean 188 days) since coronary stent had been placed. Various stents were implanted and assessed a relation between restenosis and many factors. Results : Of 58 lesions were target stenotic studies, there were 22 of restenotic lesions(37.9%), and the restenosis rate wes statistically significant difference in the relation with diabetes mellitus(p<0.05), group of acute myocardial infarction(p<0.05) among clinical diagnosis of ischemic heart disease(stable angina, unstable angina and acute myocardial infarction) in clinical factors and with high dilation pressure of stent(p<0.05) in procedural factors. When the rate of restenosis was evaluated among implanted stents, it was lowest in the Multilink^(®) stent and highest in the Nir Royal^(®) stent(60%). Conclusion : In this study of restenosis and various factors after placement of stents in the coronary artety disease, factors such as diabetes mellitus, group of acute myocardial infarction and a dilation pressure of stent were significant related with restenosis and the restenosis rate of Multilink^(®) stent was lowest and the highest restenosis rate was of Nir Royal^(®) stent.

관상동맥 스텐트 시술 후의 재협착에 관한 연구

김윤철,이정우,김보영,강정아,임대승,이민수,김정희,성보영,최성준,성인환,전은석 충남대학교 의과대학 지역사회의학연구소 2000 충남의대잡지 Vol.27 No.1

Coronary stent implacement is known as an effective treatment in the intimal dissection after percutaneous transluminal coronary angioplasty and the prevention of restenosis. However, In-stent restenosis still remains a major concern in clinical stenting. The stents were placed in 103 patients from July 1996 to March 1999 and performed follow-up coronary angiograms in 59(57.3%) patients. To identify the clinical, angiographic and procedurerelated variables 'which predict late restenosis within the stented artery, 59 patients(58.3±9.9, M:F= 41:18) were studied. The clinical characteristics of the patients were stable angina in 23(39.0%), unstable angina in 14(23.7%), acute myocardial infarction in 21(35.6%) and old myocardial infarction in 1(1.7%). Coronary stenting was performed in 1 patient(1.7%) for primary lesion, 50 patients(84.7%) for suboptimal results after PTCA, 6 patients(10.2%) for bail-out procedure, and 2 patients(3.4%) for restenotic lesions. All patients were treated with aspirin and ticlopidinc. The follow-up angiograms were obtained at 7±4 months. The overall in-stent restenosis rate was 27.1%. The coronary angiographic findings were 32 single vessel(54.2%), 19 two vessel(32.2%) and 8 three vessel disease(13.6%). The angiographic morphological characteristics were type A in 33(55.9%), type B in 14(23.7%), type C in 12(20. 3%) cases. Variables of 16 patients with restenosis were compared with those of 43 patients without restenosis. Previously known predictors for in-stent restenosis were multiple stenting, stenting for restenotic lesions, residual stenosis after stenting, stenting for total occlusion lesions, reference diameter, balloon to vessel ratio, acute gain and minimal luminal diameter after procedure, design and characteristics of stents, ostial lesion of aorta, high pressure method for stenting, lesion length, diabetes mellitus, size of artheroma, saphenous vein grafts, ulcerlating lesions and calcified lesions. In this study, Reference diameter before stenting(2.43±0.54mm vs. 2.88±0.65mm, p=0.016) and balloon-to-artery ratio(1.28±0.26 vs. 1.11±0.18, p=0.006) were predictors for in-stent restenosis. 1) The overall in-stent restenosis rate was 27.1%. 2) In the analysis of predictors for in-stent restenosis, there was no significant differences in clinical, angiographic factors between group with restenosis and without restenosis. But, Only reference diameter before stenting and balloon-toartery ratio were predictors of late in-stent restenosis. In conclusion, stenting is effective revascularisation method for selected patients with ischemic heart disease, and to minimize in-stent restenosis rate, stent implanting is achieved in a large vessel on the basis of an artery-to-stnet ration of 1:1, if possible.

관상동맥 스텐트 내 재협착의 발생에 미치는 임상적 관동맥 조영술적 요인들

윤혁준,김기식,박형섭,이영수,현대우,한성욱,허승호,김윤년,김권배,박남희,원경숙 대한순환기학회 2003 Korean Circulation Journal Vol.33 No.12

Therapeutic Strategy for In-Stent Restenosis Based on the Restenosis Pattern After Drug-Eluting Stent Implantation

김기훈,김두일,김일환,김종윤,한양천,설상훈,김웅,양태현,김대경,김동수,이상희,박종선,김영조,신동구,조윤경,남창욱,허승호,김권배 대한심장학회 2009 Korean Circulation Journal Vol.39 No.10

Background and Objectives: The aim of this study was to evaluate the outcomes of repeated percutaneous coronary intervention (PCI) based on the restenosis pattern in drug-eluting stent (DES) failure. Subjects and Methods: From April 2003 to March 2006, all 67 patients (67 lesions) at our 3 centers who had DES in-stent restenosis (ISR) were enrolled. The patients were divided into 3 groups: group I had focal edge restenosis, group II had focal body restenosis, and group III had non-focal restenosis. All patients were treated with conventional PCI including plain old balloon angioplasty (POBA), cutting balloon angioplasty (CBA), and repeated DES implantation (Re- DES). Angiographic and clinical one year follow-up results for the 3 groups were evaluated. Results: Sixteen patients were enrolled in group I, 36 in group II, and 15 in group III. Baseline clinical and angiographic characteristics and the proportion of patients in each group receiving each type of treatment strategy were not significantly different among the groups. Within each group, a comparison of angiographic and clinical outcomes for each therapeutic modality revealed that restenosis rates were not statistically different. Although rates of major adverse cardiac events (MACE) were not statistically different between groups I and II, in group III, MACE were 3-fold higher for the POBA (4/4, 100.0%) and CBA (4/4, 100.0%) subgroups than for Re-DES (1/3, 33.3%) (p=0.06), but the differences did not reach statistical significance. Conclusion: The present study suggests that treatment of DES ISR should be individualized according to restenosis pattern: any PCI strategy appears appropriate for focal ISR patterns, while Re-DES might be a better choice for non-focal ISR patterns. Background and Objectives: The aim of this study was to evaluate the outcomes of repeated percutaneous coronary intervention (PCI) based on the restenosis pattern in drug-eluting stent (DES) failure. Subjects and Methods: From April 2003 to March 2006, all 67 patients (67 lesions) at our 3 centers who had DES in-stent restenosis (ISR) were enrolled. The patients were divided into 3 groups: group I had focal edge restenosis, group II had focal body restenosis, and group III had non-focal restenosis. All patients were treated with conventional PCI including plain old balloon angioplasty (POBA), cutting balloon angioplasty (CBA), and repeated DES implantation (Re- DES). Angiographic and clinical one year follow-up results for the 3 groups were evaluated. Results: Sixteen patients were enrolled in group I, 36 in group II, and 15 in group III. Baseline clinical and angiographic characteristics and the proportion of patients in each group receiving each type of treatment strategy were not significantly different among the groups. Within each group, a comparison of angiographic and clinical outcomes for each therapeutic modality revealed that restenosis rates were not statistically different. Although rates of major adverse cardiac events (MACE) were not statistically different between groups I and II, in group III, MACE were 3-fold higher for the POBA (4/4, 100.0%) and CBA (4/4, 100.0%) subgroups than for Re-DES (1/3, 33.3%) (p=0.06), but the differences did not reach statistical significance. Conclusion: The present study suggests that treatment of DES ISR should be individualized according to restenosis pattern: any PCI strategy appears appropriate for focal ISR patterns, while Re-DES might be a better choice for non-focal ISR patterns.

경흉부 심초음파를 이용한 관동맥 혈류속도 예비력에 의한 경피적 관동맥 성형술후 재협착의 비침습적인 진단

임세중,고영국,강석민,하종원,최동훈,장양수,정남식 대한심장학회 2008 Korean Circulation Journal Vol.38 No.6

Background and Objectives: Coronary flow reserve (CFR) decreases in the presence of significant coronary stenosis. Hence, CFR can be used for the detection of restenosis after percutaneous coronary intervention (PCI). However, because CFR can also be affected by other conditions such as endothelial dysfunction, microvascular damage, and left ventricular hypertrophy, the absolute value of CFR is not routinely used for detection of coronary restenosis. We hypothesized that changes in the value of CFR, rather than the absolute CFR value, are better correlated with restenosis in various clinical settings. Subjects and Methods: We studied 99 patients (71 males/28 females, mean age 58±11 years) who underwent successful PCI of the left anterior descending artery. Pre-PCI diagnoses were as follows: 37 unstable angina, 35 stable angina, 27 acute myocardial infarction. CFR using transthoracic Doppler was measured at 48 hours after PCI and at the time of follow-up angiography (6.0±1.5 months later). Coronary flow velocity was measured in the distal left anterior descending artery with a 7 MHz transducer (HDI 5,000, Philips, The Netherlands) at baseline and during intravenous infusion of adenosine (140 μg·kg-1·min-1). Mean diastolic coronary flow velocities from at least three cardiac cycles were averaged. Results: CFRs in 69 patients without restenosis were 2.55±0.99 at 48 hours after PCI and 2.93±1.00 at follow-up (p<0.005). CFRs in 30 patients with restenosis (>50% in diameter stenosis) decreased significantly from 2.70± 1.01 at 48 hours after PCI to 1.98±0.91 at follow-up (p<0.001). There was a significant difference in CFR change (ratio of CFRfollowup/CFRinitial) between the two groups. CFR change had a better receiver operating characteristics (ROC) curve than absolute CFR for prediction of restenosis [area under the curve (AUC) for absolute CFR= 0.76, AUC for CFR change=0.82]. Conclusion: Restenosis after PCI leads to a significant decrease in CFR, even in the presence of variable baseline CFR values. Serial measurements of CFR can be used to detect restenosis after PCI. Background and Objectives: Coronary flow reserve (CFR) decreases in the presence of significant coronary stenosis. Hence, CFR can be used for the detection of restenosis after percutaneous coronary intervention (PCI). However, because CFR can also be affected by other conditions such as endothelial dysfunction, microvascular damage, and left ventricular hypertrophy, the absolute value of CFR is not routinely used for detection of coronary restenosis. We hypothesized that changes in the value of CFR, rather than the absolute CFR value, are better correlated with restenosis in various clinical settings. Subjects and Methods: We studied 99 patients (71 males/28 females, mean age 58±11 years) who underwent successful PCI of the left anterior descending artery. Pre-PCI diagnoses were as follows: 37 unstable angina, 35 stable angina, 27 acute myocardial infarction. CFR using transthoracic Doppler was measured at 48 hours after PCI and at the time of follow-up angiography (6.0±1.5 months later). Coronary flow velocity was measured in the distal left anterior descending artery with a 7 MHz transducer (HDI 5,000, Philips, The Netherlands) at baseline and during intravenous infusion of adenosine (140 μg·kg-1·min-1). Mean diastolic coronary flow velocities from at least three cardiac cycles were averaged. Results: CFRs in 69 patients without restenosis were 2.55±0.99 at 48 hours after PCI and 2.93±1.00 at follow-up (p<0.005). CFRs in 30 patients with restenosis (>50% in diameter stenosis) decreased significantly from 2.70± 1.01 at 48 hours after PCI to 1.98±0.91 at follow-up (p<0.001). There was a significant difference in CFR change (ratio of CFRfollowup/CFRinitial) between the two groups. CFR change had a better receiver operating characteristics (ROC) curve than absolute CFR for prediction of restenosis [area under the curve (AUC) for absolute CFR= 0.76, AUC for CFR change=0.82]. Conclusion: Restenosis after PCI leads to a significant decrease in CFR, even in the presence of variable baseline CFR values. Serial measurements of CFR can be used to detect restenosis after PCI.

64열 다중검출 CT를 이용한 관상동맥 스텐트재협착의 평가

서명기 ( Myung Ki Seo ),고진신 ( Jin Shin Kho ),박소라 ( So Ra Park ),강영란 ( Young Ran Kwang ),강민경 ( Min Kyeng Kang ),조정현 ( Jung Hyun Cho ),안연정 ( Youn Jung An ),최봉룡 ( Bong Ryong Choi ),정영훈 ( Young Hoon Jeong ) 대한내과학회 2009 대한내과학회지 Vol.76 No.4

Background/Aims: Multidetector computed tomography (MDCT) is considered to be a noninvasive, alternative method for evaluating stent restenosis. However, the diagnostic accuracy of 16-channel MDCT for stent stenosis is reported to have severe limitations because of high-attenuation stent-related artifacts. 64-channel MDCT, which recently became available in clinical practice, has better spatial and temporal resolution than 16-channel MDCT. The diagnostic accuracy of 64-channel MDCT for stent restenosis (in-segment and in-stent) was assessed by comparing it with conventional coronary angiography. Methods: In-segment and in-stent restenosis (≥50% in diameter) were evaluated in 96 stent segments in 68 patients [61±12 years, 51 (75%) male] using both 64-channel MDCT and conventional coronary angiography. The in-stent analysis was confined to the portion of the artery covered by the stent and the in-segment analysis included the stent and 5 mm proximal or distal to the stent edges. Results: The 64-channel MDCT could evaluate stent restenosis in 93 of 96 (97%) stent segments. Quantitative conventional coronary angiography found in-segment restenosis (≥50% in diameter) in 16 of 68 (23%) patients and 16 of 96 (17%) segments. For the patients with interpretable stent segments, the sensitivity, specificity, positive predictive value, and negative predictive value of 64-channel MDCT for in-segment restenosis per patient were 63, 96, 83, and 89%, respectively; per segment they were 63, 97, 83, and 93%, respectively; and for in-stent restenosis per stent they were 82, 98, 82, and 98%, respectively. Conclusions: The diagnostic accuracy of 64-channel MDCT for assessing stent restenosis had high specificity and negative predictive value in the clinical setting. The 64-channel MDCT may be a promising, less-invasive imaging tool for stent restenosis, especially for the purpose of excluding stent restenosis. (Korean J Med 76:434-442, 2009)

성공적인 경피적 승모판 교련절개술 후 임상 경과와 재협착율

김영학,강덕현,송재관,최기준,이철환,홍명기,김재중,박성욱,박승정 대한순환기학회 1998 Korean Circulation Journal Vol.28 No.2

Effects of Arterial Strain and Stress in the Prediction of Restenosis Risk: Computer Modeling of Stent Trials

Shijia Zhao,Linxia Gu,Stacey R. Froemming 대한의용생체공학회 2012 Biomedical Engineering Letters (BMEL) Vol.2 No.3

Purpose In-stenting restenosis is one of the major complications after stenting. Clinical trials of various stent designs have reported different restenosis rates. However,quantitative correlation between stent features and restenosis statistics is scant. In this work, it is hypothesized that stress concentrations on arterial wall caused artery injury, which initiates restenosis. The goal is to assess the correlation between stent-induced arterial stress and strain and the documented restenosis rates. Methods Six commercially available stents, including balloon-expandable stents and self-expanding stents, were virtually implanted into the arteries through finite element method. The resulted peak Von Mises stress, principal stress,principal logarithm strain, as well as percentage of intimal area with abnormal higher stress were monitored. Results Positive correlation between arterial stress and strain after stent implantations and the documented restenosis rates from the corresponding clinical trials was found regardless of stent types. No statistical significant difference was observed for various stress or strain parameters serving as indicators of artery injury. Conclusions In-stent restenosis are less likely to occur as arterial mechanics are least altered by stent implantations. Optimization of stent designs to minimize the stent-induced arterial stresses and strains can reduce the arterial injury, and thus reduce the occurrence of restenosis. This work improved our understanding of the stent-lesion interactions that regulate arterial mechanics and demonstrated that arterial stress and strain could predict the risk of in-stent restenosis.

관상동맥 Microstent Ⅱ 시술후 재협착 예측인자

강경태,정명호,안영근,배열,차광수,박종철,서정평,박주형,조정관,박종춘,강정채,박옥규 대한순환기학회 1998 Korean Circulation Journal Vol.28 No.6